I love Dave Barry, he has been called the most influential humor writer since Mark Twain. If you haven’t read any of his stuff, you really should. In fact, I’ll even provide a link to his web site here: www.davebarry.com. Yes, I’m providing that before what I’m sure will be my well-written, extremely interesting content below. He’s that good.

I put that up there because I am going to use a quote of his that he put into one of his columns; he asks his readers if they are saying to themselves “Hey, I can do this! *Any* random person can do this!” And he counters that they are wrong, because “It takes a very special kind of random person to do this”.

And that’s how I’m tying this into EMS.

I work with a few EMT-Intermediates (I-99 curriculum) and some EMT-IV Techs (WI has a version of a basic that can start IVs with NS and give a few IV meds) that are very sour on the fact that they aren’t paramedics yet. They’re not sour on the fact that they do not yet wish to sit through the required education to become paramedics, but they’re sour that there are skills that they can’t do that they see their ALS counterparts doing. They see us “paragods” performing ALS skills and say, “Hey, I can do that”.

And it may indeed be true. I see these days that they keep pushing skills that were once only the domain of paramedics down to the BLS providers. Heck, that’s what EMS is entirely built upon. In the far beginnings of our profession (and we’re still really in the beginning phases) the skills that Paramedics and EMTs perform were once only the domain of physicians. If you would have asked a physician in the 70’s whether a non-physician could interpret an EKG and give relevant medications and treatment as well as he could, you probably would have gotten a very incredulous answer. EMS is all about proving to the medical profession that treatments once firmly entrenched as only for use in the hospital have a demonstrated benefit to the patient when used quickly at the patient’s side close to the onset of symptoms. EMS personnel were trained for that most probably because it just isn’t cost effective to have doctors sitting around manning ambulances.

However, the question that has come up in my mind is where the bottom of that lowering of educational requirements for advanced skill performance ends. I have seen in my career a paradoxical movement in educational standards for paramedics and EMTs. There are a smattering of disparate and yet somehow complimentary certifications in some states, but while some educational standards have improved, most of them have decreased. While a good argument can be made for EMS levels between the Paramedic and the EMT-Basic, such as the I-99 and the IV tech in WI or the Iowa Intermediate in Iowa in the sense that they allow rural communities to be able to perform some advanced skills without having to shoulder the full breadth of costs and responsibilities associated with full paramedics, they also don’t take into account that a lot of those skills require a whole heck of education to be safely performed in the outlying patient that can be harmed by inexperienced providers.

The debate that I got into with an EMT-IV Tech over breakfast the other morning went something like this. He brought up the fact that EMT-IVTs could administer Narcan to reverse heroin OD’s or other narcotic overdoses. His statement to that was that they ought to be then able to give Morphine for pain control “since we already carry the reversing agent” (in case they give the patient too much or the patient has a reaction). My thoughts are that they should not be able to, because the administration of a narcotic for anything requires a requisite knowledge of the pharmacologic, physiological, and social actions of the drug. And while yes, that could be covered in a module I could assume, why should it be? I brought up that it takes physicians years of experience to be able to tell how to identify drug seekers who want to get a high from the legal, medically prescribed narcotic. Contemporary medical journals in family practice and emergency medicine have written volumes on the topic, and still physicians can be fooled. The extrapyramidal reactions possible with morphine, including respiratory and other Central-Nervous-System (CNS) depressing features of the drug have other treatments and symptoms that can be hard to recognize for an inexperienced provider. An EMT-IVT just doesn’t have the breadth of background knowledge needed in order to judiciously use the drug safely in all cases. The fact that most of the time it would work out fine does not withstand the certain percentage of patients that could and would be harmed. I ended the argument with him by bringing up something that I’ve always remembered from paramedic school. Our lead instructor told us that our drug bag was nothing but “A big bag full of poison” if you didn’t know how to use it.

Remember, every single time any medical care provider performs any treatment of any kind on a patient they’re making the statement that “Right now, I know better than your body does. I know better than your brain, your nervous system, and better than all of your body’s self healing systems do what you need to keep living and get better”. Any time you put on a bandage, you’re telling that patient that you know better than their body does that they need to stop bleeding. Every time a paramedic or other provider uses an airway management technique they’re saying that they know how to breathe better for the patient than the patient’s own body does. Every time you give a medication to a patient you’re telling them that you know how best to control their body’s systems. Think about it. Every treatment, every time. It is a HUGE deal to be able to do this stuff, and you dang well better know your stuff.

Physicians are rooted in the quest for knowledge. Their reputation as learned individuals goes back to prehistory in one form or another. They’ve earned their vaulted place in society due to their quest for knowledge and reason and their caring for others above all else. EMS people came from physicians. I can think of no other medical profession that has a downward pressure on their educational standards. I’m saying that, because I think that EMS does. We have elements in our own ranks, and external forces that are continuously working to make us into skills monkeys that can be paid very little and know very little.

This is a big statement: Not everyone can be a good paramedic or EMT. It takes a certain intellect, sound ethical reasoning skills, and a level of professionalism that not everyone can attain.

This is another big statement: There are groups in our society that want to make it so that any random idiot can become a basically qualified one. This keeps us all down and lowers the quality of patient care… a lot.

Yet another: Us good EMS people should be really ticked off that educational standards are so dang low these days. Fight for excellence. Respect ourselves.

If you and or your service want to be able to perform advanced skills, earn the requisite knowledge through your studies and earn the level that it takes to do them. Enough is enough. I don’t believe that we should lower any more educational standards. No other group would do this, not the nurses, not the PA’s, and certainly not the physicians. Why should we? Yes, I understand that with the advent of Urban Fire Based EMS the IAFF and IAFC want to put more paramedics on the streets to increase their influence and their revenues, and that in order to do this they need to match the intellectual skills of medics with the intellectual skills needed to be a good grunt firefighter, but EMS is a MEDICAL profession built from the quest for knowledge. It should not be relegated to the technical performance of skills if X equals Y.

Heck, I think that the current level of Paramedic should be the basic level, and that Paramedics should be as independent as Physician Assistants. In fact, I’d like to see that in the future.

A topic that came up while my classmates and I were doing ER clinical rotations that can relate to your breakfast conversation. Most of us were asked by the ER tech if we wanted to start an IV. The majority asked replied, “No, I am in the Basic class”. One guy in my class started an IV. I asked him why he did. The reply was because it was cool and he always wanted to try it. What brothers me is we were not trained as Basics to do that skill. Sure I have seen it done hundreds of times while assisting ALS on runs. But I would never think that I have the skill or that I should be allowed to “try” it.

I started Fire/Ems and advanced as Firefighter, Firefighter/MFR, and currently Firefighter/EMT-B. I known what skills I can practice and have desire to try anything I have not received the training for. Just like on the fire side, I have not been properly trained on have to drive and operate my department new million dollar tower. Do I want to, Hell Yes! But I know my place and my skills and that is not one of them.

In my book there is a big gap between a Basic and a Medic. It is called all that extra time in school, studying, and doing clinicals.

emschick

Hey I've had this conversation! Except I would be considered the EMT-IV (they call us “Enhanced” in Virginia)

The class I took helped me advance my skills while still letting me work full time at my day job and be president of the rescue squad I volunteered at. We worked out of an Intermediate book and they just went through to pick and choose what they thought we needed to know. They glossed over a lot of details and our A&P section lasted about 3 hours total even though the chapter alone is 200+ pages in the book we use. I've had to do a ton of reading and research on my own to learn what I feel I need to perform these fancy new skills that I have. Could I give Morphine? Sure! Should I give Morphine? Maybe, maybe not. I have learned over the years from working with paramedics what can happen when Morphine is given but that doesn't mean they should give me the knox box key because I don't have enough knowledge to do it safely.

http://twitter.com/in_the_city Angelo

Like everything else these days it comes down to education. What I'm about to say is going to make me sound like a jerk with a swelled head but; I'm more properly educated and most likely smarter than most of my EMT basic counterparts. That may not be true in 100% of cases but more often than not it is. It's the (supposed) higher level of knowledge I have that makes me capable of doing the things a paramedic is supposed to do. ANYONE can be trained to start a line and push a bristojet of meds. Hell most of our physical skills can be learned by children. I proved that to my boss when i taught my 10 year old nephew to run our vent and set up our IV pump. Anyone can be taught to perform our monkey skills. Real paramedics have the knowledge base to understand the reasoning behind their treatment modalities. I believe with all my heart that the most important skill a medic has is his ability to do a proper and thorough assessment and to understand the findings presented to him. All that other stuff is just there to impress the ladies.

Everyone CAN do skills. Most people SHOULDN'T do them.

My two cents anyway.

http://twitter.com/in_the_city Angelo

Like everything else these days it comes down to education. What I'm about to say is going to make me sound like a jerk with a swelled head but; I'm more properly educated and most likely smarter than most of my EMT basic counterparts. That may not be true in 100% of cases but more often than not it is. It's the (supposed) higher level of knowledge I have that makes me capable of doing the things a paramedic is supposed to do. ANYONE can be trained to start a line and push a bristojet of meds. Hell most of our physical skills can be learned by children. I proved that to my boss when i taught my 10 year old nephew to run our vent and set up our IV pump. Anyone can be taught to perform our monkey skills. Real paramedics have the knowledge base to understand the reasoning behind their treatment modalities. I believe with all my heart that the most important skill a medic has is his ability to do a proper and thorough assessment and to understand the findings presented to him. All that other stuff is just there to impress the ladies.

Everyone CAN do skills. Most people SHOULDN'T do them.

My two cents anyway.

http://twitter.com/in_the_city Angelo

Id also like to add (cause I know it will vibrate your BB):Why does it seem like everyone is interested in doing my job, but no one is interested in doing it well?

JonBemtP

CKEMTP:Gonna have to agree with you. I think that EMS as a whole keeps cutting itself off at the knees by not mandating better education. If you want to play Paramedic… go to Paramedic school… don't argue for IV's or Intubation becoming a BLS skill.

You can teach a monkey how to start an IV, I'm sure. Can you teach a monkey WHEN to or not to start an IV, or run fluids, or give certain medications? Not really. There's a lot of A&P and Pharmacology knowledge that goes into being a good clinician… and we barely get into that in some Paramamedic courses… let alone a EMT-I or EMT-XYZ.

http://www.lifeunderthelights.com Ckemtp

You did buzz me, twice. And ya did it while I was taking care of a peds seizure inside of a classroom.

Thanks fer that

Jeramedic

CK, Great post. And I couldn't agree more. Great comments as well. Unfortunately, as I read this I am home sick with what can best be described as a 4 day old head infection. And for that am unable to spew forth a comment that reflects my deep passion for this issue. So, I will simply say this…YES.

http://www.nottrainedbutwetryhard.blogspot.com FireCap5

A good grunt firefighter is not a mental midget you know.

HARUMPH!!!

Otherwise, a spot on post! We need to raise the bar, not lower it. Like we do by having 20 different EMT derivatives. EMT-B and EMT-P is plenty as far as I am concerned! all these intermediate levels cause confusion as to who can do what and when. We have a bad enough time dealing with the ER personnell in this manner as it is. Lets not confuse them further as to our abilities.

Jeramedic

CK, Great post. And I couldn't agree more. Great comments as well. Unfortunately, as I read this I am home sick with what can best be described as a 4 day old head infection. And for that am unable to spew forth a comment that reflects my deep passion for this issue. So, I will simply say this…YES.

http://www.nottrainedbutwetryhard.blogspot.com FireCap5

A good grunt firefighter is not a mental midget you know.

HARUMPH!!!

Otherwise, a spot on post! We need to raise the bar, not lower it. Like we do by having 20 different EMT derivatives. EMT-B and EMT-P is plenty as far as I am concerned! all these intermediate levels cause confusion as to who can do what and when. We have a bad enough time dealing with the ER personnell in this manner as it is. Lets not confuse them further as to our abilities.

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